DECLARATION BY PERSONS WISHING TO TEACH, LEAD OR SUPERVISE ONE OR MORE PHYSICAL OR SPORTING ACTIVITIES OR TRAIN PARTICIPANTS IN RETURN FOR PAYMENT
To be submitted to the Direction Départementale de la Cohésion Sociale (or Direction Départementale de la Cohésion Sociale et de la Protection des Populations) in the département where the activity is practised or where the main activity is practised.
I.- Civil status.
Birth name :
Last name :
First name(s) :
Date and place of birth :
Nationality :
For persons born abroad, surnames and forenames of father and mother :
II – Contact details
Address :
Telephone :
Mobile :
Fax number :
E-mail address :
III – Qualifications.
For holders of French qualifications (diplomas, professional titles, certificates of professional qualification):
Type of qualification :
Activity, speciality :
Number of diploma, title or certificate :
Date and place obtained :
If diploma subject to revision, date of last revision :
For beneficiaries of a diploma equivalence (foreign diplomas from outside the European Union and the European Economic Area) :
Indicate the title of the French diploma equivalent to the holder’s diploma (refer to the equivalence certificate)
Type of qualification :
Activity, speciality :
For trainees (preparing for a French diploma) :
Title of diploma being prepared :
Start and end dates of training booklet :
Name and address of training establishment :
Date and end of work placement :
Name of placement tutor :
For holders of a licence to practise :
Date of issue of authorisation to practise (date of ministerial letter) :
Pursuant toarticle R. 212-84 of the French Sports Code, foreign diplomas are accepted as equivalent by the Minister for Sport after consulting a commission.
In addition, holders of qualifications subject to retraining must be up to date with this obligation.
IV – Supervised physical or sporting activities (not to be completed for trainees).
For employees :
Profession of sports instructor exercised as: principal or secondary occupation
Name and address of the establishment where the activity is carried out :
Activity supervised :
Discipline :
Start and end dates of activity :
Only information known at the time of declaration must be entered. Other information must be sent to the authorities as soon as it is known.
For self-employed persons:
Profession of sports instructor exercised as: principal or secondary activity
Company name :
Legal form :
SIRET number :
Address :
Telephone number :
Mobile phone :
Fax number :
E-mail address
Activity supervised :
Discipline :
Main place of practice :
Address of main place of practice :
Date of commencement of practice :
Note: This declaration must be accompanied by :
– an identity photograph complying with the specifications of standard ISO/IEC 19794-5:2005 ;
– a copy of a valid identity document;
-a copy of each of the diplomas, titles or certificates referred to and, where applicable, of the current revision certificate for qualifications subject to compulsory retraining;
-in the case of trainees, a copy of the certificate attesting to the minimum requirements prior to being placed in a teaching situation and any document attesting to tutorship (training agreement, etc.);
-for those with an equivalent diploma, a copy of the certificate of equivalence;
-for those holding a licence to practise, a copy of the licence to practise;
-a declaration on honour attesting to the accuracy of the information contained in the declaration.
They must also be able to produce proof of identity and the originals of diplomas, professional qualifications and professional qualification certificates attesting to their qualifications.
Anyone making this declaration will be required to submit a request for an extract from the criminal record (bulletin no. 2) to the national criminal records department, in accordance witharticle 776 of the Code of Criminal Procedure. The automated judicial file for perpetrators of sexual offences (FIJAIS) will also be consulted, in accordance with article 706-53-7 of the same code.
DECLARATION OF HONOUR
I, the undersigned, sports educator exercising or wishing to exercise (1) the functions set out inarticle L. 212-1 of the French Sports Code, declare that I meet the conditions set out in these provisions and that I have not been convicted of any offence prohibiting me from exercising these functions, pursuant to article L. 212-9 of the same code.
I certify that the information given in this declaration is correct.
Date and signature
(1) Delete as appropriate.
